Patient Application Form  

What kind of supplies do you need? What we can supply depends on what your insurance covers.

Meter	Yes	No 

Strips	Yes	No  

Lancets	Yes	No 

Insulin	Yes	No  (Please note in the Comments Box the type you are using)

SyringesYes	No  (Please note in the Comments Box the size and frequency)

Other, please describe:
		(for example:  pump supplies, vacuum erection therapy system, etc)

We need following information to get started:

I am submitting this form for:     

        Myself       Family Member        Friend 

 

Name of patient
Sex	Male    Female
Mailing Address
City, State and ZIP
Day-time Phone Number
Home Phone, if different
Date of Birth	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month  01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day  Year
Social Security Number
Primary Insurance (Sorry, No HMO's)	Medicare   Major Medical Champus/TriCare   No Insurance
Medicare ID #, if applicable
Name of Insurance Company
ID/Policy Number
Group Number
Phone Number
Is the patient the insured party?	Yes       No
If NO, Name of Insured
Birthdate of Insured (MM/DD/YYYY)
SSN of Insured
Secondary Insurance?	Yes       No
Name of Insurance Co
ID/Policy Number
Group Number
Phone Number
Physician's Name
Street Address
City, State, Zip
Phone Number
Fax Number
Diabetes Treatment Plan	Insulin   Pill  Insulin & Pill        Diet Only
How many tests per day
Brand of Meter currently using
Your E-mail address
FAX (If applicable)

Medical/Payment Release Authorization

Prior to shipping diabetic supplies, we are required by Medicare/Insurance Company to obtain your agreement to allow us to handle the billing on your behalf.  Agreeing to these terms now will help expedite the first shipment of your supplies upon verification of your health insurance.

I authorize the release of any medical or other information necessary for American Diabetes Services to process and submit my claims to Medicare and/or my insurance. I authorize payments for medical supplies furnished to me by American Diabetes Services be paid directly to them. I agree that if my insurance company sends me the payments, that I will send all of the payments received directly to American Diabetes Services as soon as I receive them. I give American Diabetes Services permission to contact me by telephone concerning the furnishing of Medicare covered items that are to be rented or purchased. I have reviewed the Notice of Privacy Practices available online and/or understand that I can request a printed copy.

  I agree to the terms of the Medical/Payment Release Authorization.  I understand that a paper copy of this Release will be mailed or included in the first shipment for me to sign and return immediately for company records.

I acknowledge that by submitting this application, I am initiating the services of American Diabetes Services.  Please check all that apply:

At this time, I have not contacted any other supply company for diabetic supplies.
I have made multiple applications to other companies (Please note that no supplies will ship without your verbal/written consent).

I  already use another supply company but would like to change companies. 

Enter your comments in the space provided below:

To Review our Notice of Privacy Practices